Evidence-based general practice: Selected abstracts from the 98th EGPRN Meeting, Porto, Portugal, 9–12 May 2024

Abstract With its strong commitment to Primary Care, Portugal’s healthcare landscape has witnessed significant strides in recent years. The 98th EGPRN meeting in Porto was a testament to the dedication and progress of primary care research and education in the country.The theme of the 98th EGPRN meeting, ‘Evidence-Based General Practice’, aligned seamlessly with the evolving healthcare landscape in Portugal. This paradigm shift aims to foster better interdisciplinary collaboration and establish a framework for connecting welfare and healthcare on a local community level. Over the past few decades, primary health care and general practitioners in Portugal have gained prominence, following the guidelines set forth by the World Health Organisation (WHO). With a focus on prevention and wellbeing, practices have transitioned into multidisciplinary health centres. Considering this evolving healthcare context, the need for innovative and multidisciplinary research designs becomes imperative for translating evidence into practice. Moreover, this gathering provided an opportunity to discuss the challenges and opportunities associated with population-based studies. Understanding the collective health needs of communities and implementing data-driven strategies will shape the future of evidence-based general practice in Europe.In conclusion, the 98th EGPRN meeting in Porto, Portugal, was a dynamic platform for exchange, learning, and innovation, as we collectively strive to enhance evidence-based general practice. As an academic community, we aim to chart a course towards a healthier and more interconnected future for primary care, leaving a positive impact on the wellbeing of communities and patients alike.

This lecture argued that the way we currently practice medicine is unsustainable for patients, clinicians, health systems, our societies and the planet.We need a new way to appreciate human, financial and environmental resources in healthcarewe need to understand what we do in medicine through a lens of sustainability.
For example, there is a massive mismatch between what is being recommended in clinical practice guidelines and the available time for clinicians to implement the recommended care.To follow current guidelines, US primary care physicians are estimated to require 27 hours per working day.Just to implement the European hypertension guidelines, Norway would need more general practitioners than currently in practice.More physicians (from all specialties) and five times as many nurses as currently available may be needed to implement all lifestyle interventions recommended by the National Institute of Health and Care Excellence in the United Kingdom.Were clinicians to follow these guidelines, there would be no time left to care for other ill patients and the healthcare system would collapse.
It is thus evident that clinicians face a barrage of recommendations that in total are impossible to implement.As a result, clinicians must prioritise which recommendations to follow in which patients.Without guidance, and under the pressure of time, prioritising decisions at the point of care will be implicit, variable, and likely often misguided.
One -at least partial -solution to this problem would be for guideline panels to consider the time needed to implement a recommendation when determining the direction and strength of recommendations.This requires a new methodology that highlights time constraints and provides a structure for their consideration.The Time Needed to Treat (TNT) method was introduced in The BMJ in 2023.TNT provides such a structure for how guideline panels can consider the time needed to implement the recommended care.The ultimate goal of estimating TNT is to avoid clinicians and patients spending their limited time together on recommendations with smaller rather than greater importance to the individual patient, as well as to improve access to care for patients with the greatest need of medical attention.

Bruno Heleno
nova Medical School lisbon and General practitioner at uSf das conchas in lisbon CONTACT bruno.heleno@nms.unl.ptThis lecture covered patient stories to highlight the dual challenges and opportunities in evidence-based general practice.Like many clinicians, we navigate the tension between adhering to patient-centred care and evidence-based principles within a pay-for-performance framework.However, by returning to the original foundations of evidence-based practice-combining high-quality evidence, clinical expertise, and patient preferences-we find a way to bridge this gap.Key components of the patient-centred clinical method, such as 'exploring health, disease, and illness' and 'understanding the whole person, ' are instrumental in applying evidence-based practice effectively.Similarly, the 5A's of evidence-based practice-assess, ask, acquire, appraise, and apply-enrich our discussions and aid in 'finding common ground' with our patients.
The challenge intensifies with the increasing interference of vested interests in clinical autonomy.Commercial influences, for instance, significantly sway the production of evidence, affecting which diseases are prioritised and how interventions are evaluated.Moreover, the rise of structured templates, point-of-care prompts, and pay-for-performance incentives often shifts the focus from patient care to management targets.Nonetheless, evidence-based practice remains a powerful tool against these pressures.It equips us with the critical thinking skills needed to question the relevance and robustness of evidence and to ensure our clinical decisions align with patient needs.
In summary, evidence-based practice serves as a foundation for not only addressing the challenges we face but also advancing healthcare in a way that truly benefits patients.It promotes a critical evaluation of evidence and a commitment to patient-centred care, offering tools to resist commercial and unreasonable managerial pressures.Notable advances in the last 30 years are a broader sense of what constitutes evidence, how to ensure that the voices of patients shape which evidence is produced, and more transparent methods of translating research findings into clinical recommendations.We still need evidence about better ways of understanding each patient as a whole person, or of finding common ground.These are great opportunities for general practice to be even more evidence based.

Decision aids in primary healthcare -needs and experiences
Mafalda Proença-Portugal a,b , Bruno Heleno a,b , Sónia Dias a,b , Ana Gama a,b and Sofia Baptista a,b a uSf da Baixa, ulS São José, lisboa, portugal; b noVa Medical School, universidade noVa de lisboa, lisboa, portugal CONTACT mafaldapportugal@gmail.com Background: Decision aids (DA) are evidence-based tools that support shared decision-making, promoting an active role of patients in health decisions.Portuguese clinical guidelines are tools for clinical decision-making but have low incorporation of patient's values and perspectives.However, the complexity of available information and the ambiguity between choices call for the patients' participation in the decision-making process.DA adapted to the Portuguese reality could be useful in primary healthcare (PHC).Research questions: To explore the perception of health professionals about DA and their utility within the scope of PHC in Portugal; to identify barriers and facilitators to the implementation of DA in clinical practice; and to identify clinical topics that would benefit from translation and cultural adaptation.Method: Qualitative study.Seven focus groups were held with 33 general practitioners and residents (more than 6 months of residency).Discussions were recorded, transcribed, and anonymised, then thematically analysed by two authors independently.The Regional Health Administration of Lisbon and Tagus Valley Health Ethics Committee approved the study.Results: Most participants were not familiar with the concept of DA.All participants mentioned that DAs support the professional's clinical decision and only one mentioned their potential to support shared decision-making with their patients.Participants generally revealed a positive attitude towards the use of DA.Concerns surrounded the lack of funding and the need for longer consultation time.Participants mentioned as facilitators: the possibility of integrating these tools into computer systems and their translation and adaptation to the Portuguese population.Younger and more literate patients were the most receptive to DA. Clinical topics of interest included screening, diagnosis and treatment.Conclusions: Despite being unfamiliar to most participants, integrating DA in PHC was well received and these may provide a potential added value regarding the provision of healthcare to patients KEYWORDS Decision aids; focus groups; primary healthcare; shared decision making; qualitative study THEME PAPERS

Factors-influencing primary care physicians recommending patients to use digital health technologies for self-management: A crosssectional study across 20 countries
September 2020.The outcome was a self-report recommending patient to at least one of six listed forms of digital health technologies (symptom checker/self-assessment tools, online information resources, health trackers, mindfulness apps, online counselling and crisis resolution services).Multivariate logistic regression models were performed to identify factors associated with recommending digital health technologies to patients.Results: A total of 1,592 Primary Care Physicians were included.Before the pandemic, the odds of recommending digital health technologies for self-management were lower for Primary Care Physicians not involved in teaching (aOR 0.64, 95%CI 0.51-0.8),or practising in Turkey, Australia, Chile, Colombia, France, Italy, Poland, Portugal, Slovenia, and Spain (aORs range: aOR 0.18, 95%CI 0.1-0.34[Turkey]; aOR 0.58, 95% CI 0.36-0.93)[Australia]).There was no significant difference in recommending digital health technologies before and during the pandemic (53.2% vs 54.7%, p = 0.215).Conclusions: Involvement in teaching (pre-pandemic) and practising in a rural setting (during the pandemic) positively influenced the recommendation of digital health technologies.Significant variation in recommending digital health technologies was present across countries.Further research is indicated to better understand potential drivers of variation, including characteristics of the populations served, as well as national health systems and policies.

Improving medication review and cardiovascular risk management in patients using antipsychotics in general practice -a pilot study
Karlijn Van Den Brule-Barnhoorn, Kirsti Jakobs, Sietske Grol, Jan Van Lieshout, Marion Biermans and Erik Bischoff radboudumc, nijmegen, netherlands CONTACT karlijn.vandenbrule-barnhoorn@radboudumc.nlBackground: Patients using atypical antipsychotic medication (APM) have a significantly increased cardiovascular risk (CVR).However, monitoring of CVR in general practice (GP) is insufficient due to a lack of knowledge and time.TACTIC is a one-time transmural intervention aimed at reducing inappropriate APM use and CVR in patients in GP.TACTIC consists of an information meeting, a multidisciplinary meeting with the patient, and a follow-up consultation with the GP in which an individualised treatment plan is drawn up.We investigated the feasibility of TACTIC in a qualitative pilot study to optimise the intervention for application in an upcoming RCT.Research questions: What are the barriers and facilitators for the feasibility of TACTIC according to patients and healthcare professionals?What are the suggestions for improvement for the intervention?Method: Patients, selected through purposive sampling, were invited for individual interviews.Healthcare professionals were invited for focus group interviews.Interviews were semi-structured and interview guides were based on the Normalisation Process Theory.We used the Framework Method for analysis of our data, to identify themes.We applied the Consolidated criteria for Reporting Qualitative research (COREQ) guidelines.

Results:
We conducted eight individual and two focus group interviews, with 11 healthcare professionals in total.This resulted in several important facilitating factors: a personal approach, a clear information meeting, and a summary with advice from the psychiatrist after the multidisciplinary meeting.Barriers appeared to be the high workload for GPs when recruiting participants, the relatively short duration of the multidisciplinary meeting and the tension/anxiety patients felt during participation.Suggestions for improvement included indication, management of patients' expectations, communication and data flow between healthcare professionals.Conclusions: This qualitative analysis uncovered various barriers and facilitators, and useful suggestions for improvement, which we will use to further, develop the TACTIC intervention in preparation for the upcoming RCT.

Maxime Pautrat
Maison de Santé pluridisciplinaire, Médecine Générale, ligueil, france CONTACT lamibaryton@hotmail.fr Background: The sexuality of the elderly is the focus of recent research, but still rarely discussed during primary care consultations.
Research questions: This study aimed to describe the practice of general practitioners (GPs) and to explore what GPs think about communicating about the sexuality of elderly people (EP).Method: Mixed study included quantitative and qualitative study, carried out between June 2021 and June 2022 among GPs.The quantitative study included a descriptive analysis, based on an anonymous questionnaire designed by the investigators and distributed by mailing via professional structures.It included the usual demographic data completed with questions about sexuality.The qualitative study was an inductive analysis inspired by grounded theory.It aimed to conceptualise the representations of GPs recruited by a snowball effect, based on individual semi-directed interviews.Results: One hundred and five questionnaires were analysed.There was a significant link between male gender and comfort (p < 0.05).GPs who were 'at ease' were significantly older than those who were 'not at ease' (p < 0.05).Twelve GPs were interviewed.During the interviews, they reaffirmed their role as being 'in the best place' while expressing their 'discomfort' .A patient-centred approach was favoured, with a 'trusting' approach that went beyond 'Judeo-Christian modesty' .The GPs reported a transference phenomenon linked to their personal and professional experience.'Resistance, it's simple, it's always on the doctor's side' testified to their reflexivity.Conclusions: GPs' perceptions of how to deal with the sexuality of EP led to the emergence of new proposals, such as not limiting sexuality to coitus, combating societal taboos, and promoting mutual support in peer groups.This study opens other avenues for reflection, such as screening for even old cases of violence and sexually transmitted infections, which are often overlooked in the over-60s.

Frailty and its association with long-term mortality among community-dwelling older adults aged 75 years and over
Maor Lewis, Galia Zacay, Anthony Heymann and Dan Justo Meuhedet Health Services, tel aviv, israel CONTACT maorlew@gmail.comBackground: The prevalence of frailty in a population of community-dwelling older adults and its association with long-term mortality has not been previously studied in Israel on a large scale.

Research questions:
We sought to demonstrate the potential utility of a frailty index in a large database of communitydwelling older adults aged 75 years and over in Israel by studying the prevalence of frailty and its association with long-term mortality in this population.Method: A retrospective cohort study using a large Israeli Health Maintenance Organisation database.The prevalence of frailty and its association with all-cause mortality was studied among older adults aged 75 years and over who were followed for 2-8 years.The Frailty index was calculated using the cumulative deficit method including 28 chronic diseases and age-related health deficits.Results: The cohort included 43,737 community-dwelling older adults: median age was 77 years (IQR 75-82 years); 19,300 (44.1%) patients were males; most patients were non-orthodox Jews (n = 35,515,81.2%). Overall,19,396 (44.3%) older adults were frail: 12,260 (28.0%) mildly frail, 5,533 (12.7%) moderately frail, and 1,603 (3.7%) severely frail.Overall, 15,064 (34.4%) older adults died during the follow-up period: 4,782 (39.0%) mildly frail, 3,016 (54.5%) moderately frail, and 1,080 (67.4%) severely frail.Cox regression analysis showed that mortality was associated with severe frailty (HR 2.63, 95%CI 2.45-2.80),moderate frailty (HR 2.05, 95%CI 1.96-2.14),and mild frailty (HR 1.45, 95%CI 1.39-1.51),controlled for age, gender, and population sector.In patients aged 90 years and over, there were no longer differences in cumulative survival between patients with moderate and severe frailty (p = 0.408).Conclusions: Frailty is common among the population of community-dwelling Israeli older adults aged 75 years and over and associated with long-term mortality across frailty levels.Among older patients aged 90 years and over there are no longer differences in cumulative survival between patients with moderate and severe frailty.KEYWORDS Community-dwelling; cumulative deficit; frailty; mortality; older adults

Ukrainian refugees healthcare resource utilisation in Israel
Background: About one million people are in need of healthcare at home in Germany.This is a mostly complex endeavour because interprofessional collaboration is often challenging.This might have a negative impact on patient safety.Research questions: How do people receiving home care (PRHC), relatives, registered nurses from home care services, general practitioners (GP) and therapists (occupational-, physio-, speech therapists) perceive interprofessional collaboration in the home care setting?Method: Semi-structured interviews were conducted with 20 PRHC and 21 relatives.Additionally, we performed nine monoprofessional focus groups involving nurses of home care services (n = 17), GP (n = 14), and therapists (n = 21).Data were analysed by qualitative content analysis.Results: Three main categories were identified: (a) 'perception of interprofessional collaboration' , (b) 'means of communication' , and (c) 'barriers and facilitators' .PRHC and relatives often perceive little to no interprofessional collaboration and take over a significant part of the organisational coordination and information exchange.Interprofessional collaboration in steady care situations does exist at times and mostly concerns coordination tasks.Contact and information exchange are rare.However, interprofessional personal encounters are sporadic.Fixed agreements and permanent contact persons are not standard but increase with the complexity of the healthcare situation.Joint collaborations are often perceived as highly beneficial.Means of communications such as telephone, fax, or E-mail are used differently and are often considered tedious and time-consuming.In general, no interprofessional formal written or electronic documentation system exists.Personal acquaintance and mutual trust are beneficial, while a lack of mutual availability, limited time, and inadequate compensation hinders interprofessional collaboration.Conclusions: Interprofessional collaboration in-home care occurs irregularly, and coordination often remains with PRHC or relatives.While this individual care setup may work relatively straightforwardly in care situations of low complexity, it becomes vulnerable to disruptions with increasing complexity.Close interactions, collaboration, and fixed means of communication might improve healthcare at home.KEYWORDS Interprofessional relations; home healthcare; family; health professions FREESTANDING PAPERS

How do Norwegian GPs experience participation in mandatory groups for continuing medical education?
Torunn Bjerve Eide Dept of General practice, university of oslo, oslo, norway CONTACT torunnbjerveeide@gmail.com Background: To ensure high quality services in general practice, we need both a comprehensive specialist education as well as evidence-based professional development after specialisation.Norwegian GP specialists participate in mandatory Continuing Medical Education (CME) groups.We lack research on the GPs experience and evaluation of these groups.Research questions: How do current CME groups function both organisationally and in terms of content?What do GPs perceive as the groups' most important functions and needs for improvement?Method: All Norwegian GPs were invited to participate in the study.A questionnaire was developed and piloted by experienced general practitioners and researchers.The questionnaire includes both closed-ended and free-text questions.Collected data will be analysed quantitatively and with thematic analysis as described by Braun and Clarke.Results: Five hundred and seventy-nine GPs answered the questionnaire, 59% were female, and 89% were GP specialists.The CME groups consisted of from 2 to 17 participants (median 6).Thirty-eight per cent of the groups consisted of GPs working together, while the remaining groups consisted of GPs from different practices.The mean time of participation in the same CME groups was 10 years (range 0 to 45).Almost 91.5% of respondents were happy or very happy with the total experience in their CME group.The groups were seen as important not only as a compulsory activity but also for quality improvement, professional updates and even a social setting.Many expressed that the groups gave essential support when dealing with professionally difficult issues.Some called for an idea bank for subjects to discuss in the groups, however, many emphasised that the groups functioned very well as they were.Conclusions: Norwegian GPs reported very positive experiences with their mandatory CME groups.As the GPs everyday work can be relatively lonely, the groups role as a professional and emotional sounding board was seen as important.Further findings will be presented at the congress.KEYWORDS Continuing medical education; quality improvement; professional update; mixed-methods

Characterisation, symptom pattern and symptom clusters from a retrospective cohort of long COVID patients in primary care in Catalonia
Gemma Torrell, Diana Puente, Constanza Jacques Aviñó, Israel Rodriguez-Giralt, Lucía Amalia CarrascoRibelles, Concepció Violán Flors, Veronica Royano, Alba Molina Cantón, Tomás López Jiménez, Laura Medina Perucha 1 and Anna Berenguera 1 institut català de la Salut, Barcelona, Spain CONTACT gemmatorrell@gmail.comBackground: Around 10% of people infected by SARS-COV-2 report symptoms that persist longer than 3 months.Little has been reported about sex differences in symptoms and clustering over time of non-hospitalised patients in primary care settings.Research questions: What are the characteristics and evolution of symptoms over time in patients with Long COVID visits at primary care settings in Catalonia?Method: Descriptive study of a primary care cohort of patients with symptoms' persistence ≥3 months from clinical onset in co-creation with the Long Covid Catalan group using an online survey.Recruitment: March 2020-June 2021.Exclusion criteria: being admitted to ICU, <18 years old, not living in Catalonia.117 symptoms were gathered in 18 groups.A cluster analysis was performed at 21 days of infection (baseline), 22-60 days and ≥3 months.Results: We analysed responses of 905 participants (80.3% women).General symptoms were the most prevalent with no differences by sex, age, or wave.Its frequency decreased over time.Dermatological (52.1% in women,28.5% in men), olfactory (34.9%, 20.9%) and neurocognitive symptoms (70.1%, 55.8%) showed the greatest differences by sex.Cluster analysis showed five clusters with a predominance of 'Taste & smell' (24.9%) and 'Multisystemic' clusters (26.5%) at baseline and' Multisystemic' (34.59%) and 'Heterogeneous' (24.0%) at ≥3 months.The 'Multisystemic' cluster was more prevalent in men.The 'Menstrual' cluster was the most stable.Most transitions occurred from 'Heterogeneous' cluster to 'Multisystemic cluster' and from 'Taste & Smell' to 'Heterogeneous' .Conclusions: General symptoms were the most prevalent in both sexes at three-time cut-off points.Major sex differences were observed in dermatological, olfactory and neurocognitive symptoms.The increase of the 'Heterogeneous' cluster might suggest an adaptation to symptoms or a non-specific evolution of the condition, which can hinder its detection at medical appointments.A careful symptom collection and patients' participation in research may generate useful knowledge about Long Covid presentation in primary care settings.

Exploration of sexuality in women after sexual violence
Emeline Pasdeloup, Chloé Duboc and Mathilde Leblanc faculté de Médecine de tours, ouzouer sur loire, france CONTACT epasdeloup45@gmail.comBackground: In France, 15% of women report having been the victim of at least one sexual assault in their lifetime.The impact of such violence on health in general is well known, but the consequences for sexual health are poorly assessed.